NPIMap

Organization Active NPI

Wellmont Health System

Doing business as Bristol Regional Medical Center

  • General Acute Care Hospital
  • Bristol, TN
National Provider Identifier
1124058615
Registry record updated Apr 16, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
Legal business name
WELLMONT HEALTH SYSTEM
Doing business as
Bristol Regional Medical Center
Practice address
1 Medical Park Blvd
Bristol, TN 37620-7430
Phone
(423) 844-1121
NPI assigned
Jul 3, 2006
Last updated
Apr 16, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 16, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shane Edwin Hilton
Title
Evp/Cfo
Phone
(423) 302-3467

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Acute Care Hospital 282N00000X Primary

Addresses

Primary practice location

1 Medical Park Blvd
Bristol, TN 37620-7430

Mailing address

311 Princeton Rd Ste 1
Johnson City, TN 37601-2026
Phone (423) 844-1121

Other identifiers 12

IdentifierTypeStateIssuer
004400127MedicaidVA
0440012MedicaidTN
6530115OtherTNAETNA
A3762106MedicaidTN
1000319OtherTNTN BLUE CROSS
1377051OtherTNUMWA
10260BMedicaidSC
166592403OtherTNPOSTAL WORKERS DEPT LAB
240867OtherVAANTHEM
100020309MedicaidTN
A3762106OtherTNUHC RIVER VALLEY
033361400OtherTNBLACK LUNG

Other names 1

  • BRISTOL REGIONAL MEDICAL CENTER Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://67.32.31.88:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service Other WELLMONT HEALTH SYSTEM

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN, VA3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20031223000853 TN Part B Supplier - Clinic/Group Practice 2567360704 Receives reassigned benefits from 4 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Bristol, TN; Kingsport, TN; Sneedville, TN
O20040608000164 VA Part A Provider - Hospital 2567360704 Practice locations: Bristol, TN
O20180125002244 TN Part B Supplier - Intensive Cardiac Rehabilitation 2567360704 Practice locations: Bristol, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124058615. Details of each certification follow.

Hospital certification: CCN 440012

Legal name
WELLMONT HEALTH SYSTEM
Doing business as
BRISTOL REGIONAL MEDICAL CENTER
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Aug 4, 2010
Beds
282
Ownership / control type
Hospital district or authority
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1996 in TN
Enrollment address
1 Medical Park Blvd
Bristol, TN 37620-7430
Other Hospital Practice Location
Hospital subgroups
General, Acute care, Psychiatric

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Care Compare: Hospital

Medicare Care Compare
Listed as
Wellmont Bristol Regional Medical CenterCCN 440012 · All quality measures
Overall star rating
2 of 5
Type
Acute Care Hospitals
Ownership
Government - Hospital District or Authority
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory
Tax ID family
Wellmont Bristol25 organizations share this tax ID, including this one

Other organizations with this tax ID 24

Organizations that report the same tax identification number in the National Provider Directory.

View all 24

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Shane Hilton Individual Corporate OfficerEvp/Cfo Apr 4, 2024
Corporate DirectorEvp/Cfo Apr 4, 2024
Gregory Wilgocki Individual Corporate DirectorSVP Feb 1, 2018
W-2 Managing EmployeeSVP Feb 1, 2018
Wellmont Health System Organization, Johnson City, TN Corporation 5% Or Greater Direct Ownership Interest Jul 1, 1996 100%
Ballad Health Organization, Johnson City, TN Corporation, Non-profit 5% Or Greater Indirect Ownership Interest Feb 1, 2018 100%
Marvin Eichorn Individual Corporate OfficerEvp/Cao Feb 1, 2018
Corporate DirectorBoard Member Feb 1, 2018
Buford Deaton Individual Corporate OfficerEvp/Coo Feb 1, 2018
Corporate DirectorBoard Member Feb 1, 2018
Alan Levine Individual Corporate OfficerCeo/President Feb 1, 2018
Corporate DirectorBoard Member Feb 1, 2018
Julie Bennett Individual Corporate OfficerEvp/Clo Feb 1, 2023
Corporate DirectorBoard Member Feb 1, 2023

Owners & managing parties with NPI records 8

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 9

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Hawkins County Memorial HospitalRogersville, TN, CCN 440032 Hospital 5% Or Greater Indirect Ownership Interest (100%) Apr 6, 2000
Lonesome Pine HospitalBig Stone Gap, VA, CCN 490114 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2007
Lonesome Pine Hospital Swing Bed UnitBig Stone Gap, VA, CCN 49U114 Hospital 5% Or Greater Direct Ownership Interest (100%) Jan 19, 2007
Dickenson Community Hospital, Inc.Clintwood, VA, CCN 491303 Hospital 5% Or Greater Direct Ownership Interest (100%) Feb 28, 2021
Greeneville Community HospitalGreeneville, TN, CCN 440050 Hospital 5% Or Greater Indirect Ownership Interest (100%) Dec 8, 2016
Norton Community Rehabilitaion UnitNorton, VA, CCN 49T114 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2007
Dickenson Community Hospital Psychiatric UnitClintwood, VA, CCN 49M303 Hospital 5% Or Greater Direct Ownership Interest (100%) Feb 28, 2021
Norton Community Hospital SNF UnitNorton, VA, CCN 495374 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Adp of the SNF		 Aug 1, 2007
Apr 1, 2004
Bhrhc DickensonClintwood, VA, CCN 493463 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Feb 28, 2021

Owned or controlled facilities with NPI records 9

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 40

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 40

Practitioners & affiliated clinicians

Practitioners 27

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 27

Affiliated clinicians 776

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 776

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151884800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1713225600000",
    "number": "1124058615",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "311 PRINCETON RD STE 1",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376012026",
            "telephone_number": "423-844-1121"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 MEDICAL PARK BLVD",
            "city": "BRISTOL",
            "state": "TN",
            "postal_code": "376207430",
            "telephone_number": "423-844-1121"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLMONT HEALTH SYSTEM",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-03",
        "last_updated": "2024-04-16",
        "certification_date": "2024-04-16",
        "status": "A",
        "authorized_official_last_name": "HILTON",
        "authorized_official_first_name": "SHANE",
        "authorized_official_middle_name": "EDWIN",
        "authorized_official_title_or_position": "EVP/CFO",
        "authorized_official_telephone_number": "423-302-3467"
    },
    "taxonomies": [
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004400127",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0440012",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "6530115",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "A3762106",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TN BLUE CROSS",
            "identifier": "1000319",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UMWA",
            "identifier": "1377051",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10260B",
            "state": "SC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "POSTAL WORKERS DEPT LAB",
            "identifier": "166592403",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "240867",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100020309",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UHC RIVER VALLEY",
            "identifier": "A3762106",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLACK LUNG",
            "identifier": "033361400",
            "state": "TN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://67.32.31.88:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1340.1",
            "affiliationName": "WELLMONT HEALTH SYSTEM",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "1.5, 1.6",
            "address_1": "1 Medical Park Blvd",
            "city": "Bristol",
            "state": "TN",
            "country_code": "US",
            "postal_code": "376207430",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "BRISTOL REGIONAL MEDICAL CENTER",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "BRISTOL REGIONAL MEDICAL CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bristol, TN

Sources for this page

Verify at the official NPI Registry.